The most valuable skill to develop and hone

Introduction

As medical offices, clinics and hospitals move to electronic/digital medical records, skilled use of these devices is critical to modern medical practice. While nursing and other ancillary staff can get away with asking questions (usually from a form) and typing answers as a patient answers those questions, a physician can’t afford to perform in that manner. This means that there are some vital skills that must be mastered as quickly as possible.

Clerical skills

Yes, information is generally entered into digital record systems via keyboarding. As a physician, one needs to be skilled at keyboarding to become efficient in completing medical records as quickly as possible. If you did not have a mother who insisted that I “learn to type” so that I could make some college cash typing papers for my classmates, then you will need to learn to type accurately and efficiently. There are many convenient typing instruction programs on the market. Choose one (or borrow one) and learn to type. This skill takes practice, well, learning to obtain a medical history took practice too, and takes constant work in terms of learning the proper finger positions for the keys so that one can type without staring at the keyboard.

Communication skills

Almost daily, I hear from my patients that the medical student, physician assistant student or resident is “so busy staring at the computer that they don’t look me in the eye”. This practice is interpreted by the patient as non-communication. “He was so busy tying to fill out the form that he didn’t are about me”. When patients are making these types of observations, this generally means that the visit is not going to yield the best information for getting the best outcome for the patient. Patients expect their physicians to communicate verbally and non-verbally with them. If one is busy “staring at the computer” one has cut off one of the most valuable means of non-verbal communication which is eye-contact. While you may be very adept at typing and listening (I was a master of this in medical school), your patient starts to feel neglected because they feel that they don’t have your total attention. In short, eye-contact is a valuable means of communication for both you and the patient.

The patient history

The patient history is perhaps the most important aspect of the physician-patient encounter because generally if one is listening very carefully, one can get an idea of why the patient sought your care very quickly. Obtaining a good medical history does not mean that one simply fills out those check boxes on a form in the medical records system but does mean that one obtains the key information that will help identify the problem that brought the patient to your care during the history. This is why one has to become adept in allowing the patient to tell their story (in their own words) and why one has to be constantly listening and processing the information, not attempting to fill in check spaces.

One has to constantly review and upgrade their history-taking skills as long as they are in patient care. Find a good history taking flow and stick with it long enough to make sure that you are efficient. Once you become efficient with the flow of the history, fine-tune that flow so that you can add or subtract items as the patient care situation directs. As you learned from your physical diagnosis course in medical school, the patient directs the history which directs the physical exam which directs the assessment which directs the plan. If you neglect any aspects of obtaining the most accurate and complete patient history, it will follow that your examination, assessment and plan will be neglected too.

When a patient enters my care, especially for the first time, I ask them to spell their name (sometimes those sheets are wrong) and I ask them for their date of birth (you don’t want to end up with notes on the wrong patient). After that, I put my pen, notebook, computer or tablet down and sit across from the patient and listen. I have my check list (form) in my mind so I don’t have to keep referring to a form or computer. This skill during initial history-taking, frees me to concentrate on communicating with the patient fully. I learned to keep the initial patient history in my memory long enough to either dictate it into my medical record or enter it after the patient has left my care.

I also learned to perform a review of systems while I am examining the patient. As I examine the patient’s head, I ask questions about any symptoms related to the head and move to the eyes, ears and so forth. If my exam is to be focused, then I just go through the systems are are related to the initial chief complaint and make sure that I ask about things that are move peripheral towards the end of the encounter. Again, I made sure that I became adept at either dictation or writing in performing these tasks so that my patient feels that they have my complete and undivided attention.

The patient

Novice physicians always feel that they are going to miss asking about some important fact which will result in a poor outcome for the patient. If one sits and thinks about good communication skills and obtaining the most relevant information, then one is less likely to miss something important. Another way to think of this is to think of yourself as a news media reporter who is on a city hall beat. When you first begin on your beat, you don’t know all the players well but you start to make observations and note what and who is key to your getting the best information. This same skill applies to getting the best information from your patients. You have such a short window of time in which to gather information thus you must use the best observations and make mental notes of what is most important. The more one practices this skill, the more one becomes accustomed to their “beat” so to speak, and the better the information obtained.

If your patient feels as if you are so rushed or that you are not interested in working with them i.e., you are more focused on getting your note in the computer, they they have a propensity to stop trying to communicate well with you. In short, if you have a patient who feels more uncomfortable with you in addition to the discomfort that brought them into your care in the first place, you have a situation that can’t turn out well for either you are the patient. In these days of patient satisfaction surveys, one cannot afford to concede even the smallest item because of trying to keep up with a medical records system.

The medical records system

While these digital masterpieces are wonderful for making sure that everyone involved with a patient has up to date information and billing, they vary in ease of use and interface. The data obtained from these records is only as good as the data that is entered into these records. When one enters a health care system, becoming fully familiar with the electronic data system is a significant part of one’s orientation to the place. Most large health care systems will use one system which was chosen by a few of their members but every employee has to work with and in that system. It is vitally important that you as the trainee or new employee receive a solid orientation on the system that you use so that your patient’s records remain secure and accurate.

If you are or become the person who is in charge of selecting a new electronic medical records system, you need to be fully familiar with the system that you are evaluating, the ease of entering information and making sure that everyone who uses the system is able to navigate the interfaces that apply to their specific jobs. Don’t rely completely on the sales person for a particular electronic medical records system because that person’s loyalty is with their company first (they want you to buy their product) and any potential commission that they might make in selling their product to you. This means that if you are in the position to evaluate potential digital software and hardware, make sure that you obtain solid advice and consultation with your company’s technical staff and that you know something about information systems yourself. In short, in today’s world of medicine, physicians have to make both clinical and administrative choices that can profoundly affect patient care. You need to make those choices from a position of having the best information possible not just being pushed by price (most expensive or cheapest systems may not be any better or worse).

Patient perception or put yourself in the patient’s place

As the physician that directly interacts with the patient, one has to make sure that every interaction is the best possible. If you want to get an idea of how you communicate with your patients, sit in front of a mirror, in your white coat and practice a patient encounter. Look at how you make eye-contact, how you hold your sitting position (one should never tower over a patient and ideally be on the same level as the patient). Make sure to time yourself and see what happens when you speed up or slow down your speech. Tape a mock patient encounter and critique yourself. You can do this with a digital camera and a colleague but look at whether or not your are actually communicating with your patients. In your practice encounter look at how your communication style changes when you are typing on a computer/tablet, writing or just looking at the patient and listening.

Read those patient surveys on a regular basis to see if you are developing any habits that may be detrimental to making your patients feel happy that they are in your care. I promise you, as a specialist, that my time is short on a regular basis but none of my patients would ever know that fact. This means that I do the following:

I never type while speaking with the patient

I never allow my cell phone or pager to be on anything except vibration/silence when I am with a patient

I do not allow my staff to interrupt me when I am with a patient unless there is a life or death emergency in the next room

Finally, I have learned to keep patient historical information in my head until I can get that information into my record system. As a surgeon, because I have to produce operative and procedure dictations, I am more adept at dictating than writing out procedures but I learn to produce both digital and written records efficiently. I generally do not take work home from the office because I always worry about patient information security as my home. I also make sure that the people that I am training learn to impart compassion, empathy and interest to their patients and not impart that they are more interested in entering information into a computer.